Rapid Investigation for Gastrointestinal Bleeding: Lessons Learned from a Fatal Case

1. From Death We Learn 2009 Rapid investigation for gastrointestinal haemorrhage Office of Safety and Quality in Healthcare Reference: Fox Inquest February 2009

2. The Case Background • A man in his 60’s presented to a tertiary hospital emergency department at night • following an episode of syncope due to a gastrointestinal bleed. • in shock • mixed altered and fresh blood on rectal examination. • symptoms consistent with both upper & lower gastrointestinal bleeding having

3. The Case Management The patient was: • resuscitated & stabilised with intravenous packed cells & intravenous fluids. • referred to surgical and medical (gastrointestinal) units However: • investigation was withheld until daylight hours.

4. The Case Outcome: in the morning & prior to investigation • The patient became hypotensive due to haemorrhagic shock. • Urgent endoscopy could not be arranged • The patient remained in the Emergency Department. • The patient died from peptic ulceration with secondary gastrointestinal haemorrhage despite aggressive attempts at resuscitation.

5. The Inquest A coronial inquest revealed: • The patient had a recent history of abdominal pain diagnosed as constipation in a general practice setting as well as a peripheral hospital emergency department. • The patient did not report self medication with aspirin and ibuprofen when asked about his usual medications. • That urgent endoscopy was indicated after the initial resuscitation but had not been requested by the medical or surgical teams. • There was uncertainty about which inpatient service (medical or surgical) was managing the patient due to clinical uncertainty about the site of haemorrhage.

6. The inquest A coronial inquest revealed: • That when endoscopy was requested, it was not immediately available • Difficulty accessing emergency surgical and gastroenterology services within office hours once day commitments are commenced if dedicated cover for such events is not pre-arranged. • Inconsistency between medical and nursing documentation • medical documentation could be missing • The patient’s death occurred by the way of natural causes but may have been preventable with timely and appropriate investigation and treatment.

7. Key Question Can this still happen? • Since the patient’s death, the hospital had revised its gastrointestinal haemorrhage protocol & formed an agreement with surgeons and gastroenterologist to improve emergency procedures cover. • The Deputy State Coroner recommended that the proposed plans for a High Dependency Gastrointestinal Unit with safer endoscopy suites with an extended Intensive Care Unit be progressed

8. Key messages • Gastrointestinal haemorrhage can be a rapidly progressing life threatening condition despite stabilization after initial resuscitation. • Clinically determining whether a gastrointestinal bleed is upper or lower can be difficult. • There is a need for clear pathways for the emergency management & referral of patients with gastrointestinal haemorrhage. • Where emergency services are provided, clear lines of responsibility for 24 hour coverage need to be established.